Letter to the Editor on “Risk Factors for Unplanned Admission to the Intensive Care Unit After Elective Total Joint Arthroplasty”

We read with great interest the article by Sukhonthamarn et al., entitled “Risk Factors for Unplanned Admission to the Intensive Care Unit After Elective Total Joint Arthroplasty.” This study is a timely follow-up, using a contemporary cohort, to a prior publication by the same institution [1]. This article comes at a unique time in our medical and social history, given the current coronavirus (COVID-19) pandemic due to causative pathogen SARS-CoV-2 [2]. At this time, issues of critical care triage and stewardship, along with general concerns with resource utilization and planning, prove paramount.

While we note that the results of this study are somewhat different when compared with both the authors’ prior publication [1], as well as prior publications from another institution [3,4], the generalized message remains true: increasing complexity of comorbidities and type of surgery (e.g., revision surgery or bilateral procedures) portend a higher risk of unplanned ICU admission.

Our main interest in commenting on this publication is to urge the authors to use their data to formulate a risk model that might predict future patient’s risk of unplanned ICU admission. As we gather more data on the constellation of risk factors that heighten risk of ICU admission, we can then move to prediction models that allow application of these findings to individual patients. Specifically, using the odds ratios of the individual risk factors from regression analysis, can the authors provide the readership a contemporary, weighted risk calculator for prospective use? We would ask the authors consider this in a future publication, incorporating previously described methodology [3].

Moreover, we ask the authors to comment on ways to triage “urgent” cases (e.g., fracture, dislocation, infection) that would warrant treatment during the COVID-19 era, and if their presented results might be altered in this current clinical environment. Can we predict how these urgent and revision cases may influence overall resource management [5,6]? Can we adequately predict unplanned ICU admission for primary and revision cases once we return back to the operating room when the COVID-19 disease curve normalizes? These questions not only would strengthen the authors’ current report, but might be used to better understand who might be at risk for higher acuity of care across all orthopedic subspecialties, when urgent cases are deemed necessary, and to plan appropriately in this time of crisis. Conversely, this may allow for selection of patients of lower risk for both the inpatient and outpatient setting to mitigate use of ICU care in the setting of high residual occupancy.